Coronary Artery Calcium Versus Pooled Cohort Equations Score for Primary Prevention Guidance
Open accessAbstract
OBJECTIVES This study sought to determine the feasibility of performing an extensive randomized outcomes trial comparing a coronary artery calcium (CAC)- versus a pooled cohort equations (PCE) risk score-based strategy for initiating statin therapy for primary atherosclerotic cardiovascular disease (ASCVD) prevention. BACKGROUND Statin therapy is standard for the primary prevention of ASCVD in subjects at increased risk. National guidelines recommend using the American College of Cardiology/American Heart Association PCE risk score to guide a statin recommendation. Whether guidance by a CAC score is equivalent or superior is unknown. METHODS CorCal (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events) was a randomized trial consenting 601 patients without known ASCVD, diabetes, or prior statin therapy recruited from primary care clinics and randomized to CAC- (n = 302) or PCE guidance (n = 299) of statin initiation for primary prevention. Enrolled subjects and their physicians made final treatment decisions. Primary outcomes compared the proportion of statin recommendations received and subject adherence over 1 year between CAC- and PCE-arm subjects. Modeled medical costs, adverse effects, and low-density lipoprotein-cholesterol (LDL-C) were additional measures of interest. RESULTS Subjects were well matched, and 540 (89.9%) completed entry testing and received a protocol-based recommendation. A statin was recommended in 101 (35.9%) CAC- and 124 (47.9%) PCE-arm subjects (P = 0.005). Compared to PCE-based recommendations, CAC-arm subjects were reclassified from statin to no statin in 36.0% and from no statin to statin in 5.6% of cases, resulting in a total reclassification of 20.6%. Physicians accepted the study-dictated recommendation to start a statin in 88.1% of CAC- vs 75.0% of PCE-arm subjects (P = 0.01). Patient-reported adherence to this recommendation at 3 months was 62.2% vs 42.2%, respectively (P = 0.009). At 1 year, statin adherence remained superior, LDL-C levels were lower, estimated costs were similar or reduced in CAC subjects, and few events occurred. CONCLUSIONS CAC guidance may be a more efficient, personalized, cost-effective, and motivating approach to statin initiation and maintenance in primary prevention. This feasibility phase of CorCal should be regarded as hypothesis-generating with respect to cardiovascular outcomes, which is being addressed in a large, longer-term outcomes trial. (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events [CorCal]; NCT03439267).
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Among individuals with diabetes, glycemic assessments should be performed using HbA1c as a measure of glycemic control over the preceding 2 to 3 months, which indicates risk for microvascular and macrovascular complications.
“Among individuals with diabetes, glycemic assessments should be performed using HbA1c as a measure of glycemic control over the preceding 2 to 3 months, which indicates risk for microvascular and macrovascular complications.52”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [52]
The Follow-up Evaluations passage lists diabetes mellitus as an exclusion criterion, and the Baseline Characteristics passage describes lipid and coronary-calcium testing rather than glycemic assessment (page numbers unavailable). Searches for HbA1c, glycemic control, and diabetes assessment found no passage addressing the claimed 2–3-month measure or its relationship to microvascular and macrovascular complications. (LLM, conf=0.78)
Experimental — accuracy not yet measuredSemaglutide improved steatohepatitis and liver fibrosis versus placebo in persons with MASH and stage 2 or 3 fibrosis.
“The ESSENCE (Research Study on Whether Semaglutide Works in People With Non-Alcoholic Steatohepatitis) trial, testing semaglutide in persons with MASH and stage 2 or 3 fibrosis, demonstrated improvement in steatohepatitis and liver fibrosis in the intervention versus placebo arm.11,52”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [52]
The Follow-Up Evaluations and Clinical Outcomes sections discuss coronary calcium–guided statin recommendations and cardiovascular events, not the ESSENCE trial. Searches for semaglutide, steatohepatitis, MASH, and stage 2 or 3 fibrosis found no passage addressing the claimed comparison with placebo. Page numbers were not available in our copy. (LLM, conf=0.78)
Experimental — accuracy not yet measuredIn one study, 60% of women with APOs attended a primary care visit within 12 months of delivery.
“in 1 study, 60% of women with APOs attended a primary care visit within 12 months of delivery”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [52]
The Study Protocol describes a cardiovascular-prevention trial of adults aged 50–85, and Follow-up Evaluations describes statin-related follow-up one year after enrollment. Searches for adverse pregnancy outcomes, postpartum visits, and delivery found no passage reporting the claimed 60% primary-care visit rate. (LLM, conf=0.78)
Experimental — accuracy not yet measured
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- Authors
- Muhlestein, J. B., Knowlton, K. U., Le, V. T., Lappe, D. L., May, H. T., Min, D. B., Johnson, K. M., Cripps, S. T., Schwab, L. H., Braun, S. B., Bair, T. L., & Anderson, J. L.
- Affiliations
- University of Utah (US)
- Intermountain Medical Center (US)
- Corresponding author
- Muhlestein, Joseph B.
- ORCID
- Venue
- JACC: Cardiovascular Imaging
- Publisher
- Elsevier BV
- Published
- 2022-05
- Volume
- 15
- Issue
- 5
- Pages
- 843-855
- ISSN
- 1876-7591 (ISSN-L)
- 1936-878X
- OpenAlex
- W4200504427
- Semantic Scholar
- c9b292280e75a0f51c67abfce9f518f1418fbba9
- Cited by
- 57
- References
- 45
- Citations by year
- 2026: 13 · 2025: 16 · 2024: 10 · 2023: 9 · 2022: 9
- FWCI
- 6.57
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- JACC. Cardiovascular imaging (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Intermountain Research and Medical Foundation
- Topics
- Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Keywords
- coronary artery calcium, Pooled Cohort Equations, risk score, statin initiation, primary prevention, atherosclerotic cardiovascular disease, cardiovascular risk stratification, statin adherence, LDL cholesterol, physician acceptance of recommendations, randomized trial feasibility, cost analysis, adverse effects, primary health centers, major adverse cardiac events
- MeSH terms
- Calcium, Coronary Artery Disease, Feasibility Studies, Humans, Cholesterol, LDL, Predictive Value of Tests, Primary Prevention, Risk Factors, United States, Risk Assessment, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Atherosclerosis, Vascular Calcification
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